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Abstract

Social support has been noted to improve health outcomes for individuals with HIV. Understanding how neighborhoods contribute to feelings of social support is beneficial to create environments where populations with HIV can be supported. This study assessed the relationship between neighborhood perceptions and social support with HIV management. A total of 201 individuals were recruited; individuals with HIV, 18 years or older, who were eligible to participate in the 2-hour interview. Psychiatric diagnostic interviews were conducted alongside assessments of social support and neighborhood perceptions; biomedical markers were abstracted from medical records. Correlations and linear regression analyses were performed to assess relationships between social support and neighborhood perceptions with HIV management biomarkers. The majority of the sample was male (68.8%) and African American (72.3%), with a mean age of 43.1 years. Overall, 78% were receiving combination antiretroviral therapy (cART) prescriptions, with 69% being virally suppressed. Fear of neighborhood activities was independently associated with receiving current cART. Reports of social support and neighborhood perceptions were highly correlated. Findings suggest that supportive home environments likely would improve perceptions of social support.

Keywords

social support neighborhood perceptions community cohesion HIV/AIDS HIV management psychiatric disorders psychological distress mental illness

Introduction

Despite advancements in HIV treatments, approximately 50,000 incident HIV infections occur annually in the United States.¹ Addressing the barriers to engagement in care will greatly enhance health outcomes among HIV-infected populations and potentially reduce HIV transmission. With the focus on the HIV treatment cascade, researchers and practitioners have clearly identified areas in the treatment cycle where individuals drop off the care continuum, specifically linkage into care, retention in care, and adherence to medication.² In order to develop and implement successful interventions throughout the care continuum, additional insights are needed to increase understanding the barriers that interrupt each stage of the continuum.

Although only an estimated 20% of infected individuals in the United States have suppressed viral loads, nearly 80% of persons engaged in care achieve virologic suppression.² Thus, increasing linkage and engagement in care remains a germane intervention point.³ Social support has demonstrated, through dimensions of emotional, tangible, affection, and positive interaction, to be a predictor of engagement in medical care and adherence to medications among individuals with HIV infection.^2,4,5 Additionally, social support has been shown to decrease psychological distress, which has shown to interrupt medication adherence.^6
–8 Therefore, developing strategies to improve social support should be an integral component of engagement in HIV care efforts on the care continuum.

Neighbors often provide social support to one another, particularly to individuals with chronic medical conditions.⁹ This type of location-based social support is often measured by social cohesion; lower reports of neighborhood social cohesion have been associated with increased sexually transmitted infections and HIV infection.^10
–12 Conversely, adverse neighborhood conditions, both physical and perceived, have been associated with poorer health outcomes among individuals with chronic diseases.^13

–16 For example, higher levels of psychological distress have been related to poorer neighborhood conditions as well as high rates of mistrust and powerlessness.^17

–20 Related to HIV infection, several studies have identified poorer health outcomes among individuals with HIV with adverse neighborhood living conditions.^17,21,22

More detailed analyses to evaluate how neighborhood characteristics and social support are related as well as their associations with HIV management are currently lacking. Specifically, the relationships between social support and neighborhood perceptions through measures of perceived neighborhood disorder, collective efficacy, and perceived fear may provide a better understanding of potential interventions to enhance engagement in HIV care.^17,23,24 This study was designed to examine how neighborhood perceptions and social support are associated and their relationship with HIV management to inform intervention development to improve community and interpersonal factors that influence individual behavior. We hypothesized that if individuals do not perceive themselves safe and supported in their neighborhood, they are likely to report lower social support and, thus, will not engage in continued HIV management behaviors.

Methods

In 2009, cross-sectional interviews were conducted with a sample of 201 participants. Individuals with HIV, 18 years or older, presenting for care at the Washington University HIV Clinic in St Louis, Missouri, were eligible to participate in the 2-hour interview. Trained interviewers conducted the computerized interview in a private room. Individuals were remunerated for participation in the study. All participants provided written informed consent before participation. The Washington University Human Research Protection Office approved all study materials.

Measures

The sociodemographic characteristics collected included gender, age, race, annual income, education level, and employment status. We utilized the Medical Outcomes Study (MOS)-Social Support Survey⁴ to assess feelings of social support, as it has been used widely. The MOS-Social Support Survey⁵ consists of 4 subscales and is as follows: emotional support, tangible support, affectionate support, and positive interaction. Each item on the scale ranges from 1 to 5, (none of the time to all of the time). Each subscale uses a mean score, thus, having the same composite range (1-5). The overall social support scale includes 1 additional item, the number of people who are primary supports in one’s life ranges from 0 to 99. Our results included an outlier who had answered 200 and was not included in the analyses. The overall social support index was calculated, with a possible range of 0 to 100.

Each item on the Perceived Neighborhood Disorder Scale¹⁸ ranges from 1 to 4 (strongly agree to strongly disagree) about their perceived level of danger in their residence.²⁵ Participant data (n = 102) with responses of don’t know/not sure and refused were removed from analyses.

The items on the Collective Efficacy Scale²⁶ range from 1 to 5 (very likely to very unlikely), assessing the social cohesion, specifically how likely are you to rely on neighbors in order to address concerns in the neighborhood.²⁶ Some examples include, neighbors being willing to help each other, feeling trust among the people in the neighborhood, and likelihood of neighborhood doing something to reduce spray graffiti on local buildings.²⁶ Participant data (n = 25) were removed from analyses when responses were don’t know/not sure and refused.

The Perceived Fear Scale²⁴ measures how many total days participants had feared personal safety, home safety, and neighborhood safety within the past 7 days.²⁴ The range was from 0 to 7. Widely accepted for diagnostic interviews both in practice and for research purposes, the Diagnostic Interview Schedule was utilized to determine current psychiatric diagnoses (within the past 12 months) with trained “laypersons.”²⁷ Additional results of these interviews are described elsewhere.²⁸ Symptoms of depression were assessed using the Patient Health Questionnaire 9¹⁵ and quality of life was measured with the Short Form 12,²⁹ as has been used previously in populations with HIV.^29,30

Data were abstracted from participants’ medical records to ascertain the most recent CD4 counts, HIV viral loads, and current prescription of combination antiretroviral therapy (cART) defined as the use of ≥3 antiretroviral drugs. HIV viral loads were used as a proxy for medication adherence, as self-reports have been reported with moderate reliability previously.³¹ Variables were dichotomized as follows: HIV viral loads (<400 copies/mL and ≥400 copies/mL), education level (≤high school graduate/general educational diploma [GED] or >high school degree), employment status (unemployed, including those receiving disability benefits, and employed, part- or full-time), annual income (≤ and >US$10 000), and CD4 counts (<200 cells/mm³ and ≥200 cells/mm³). The cART cutoff was appropriate, considering the test sensitivity at the time of data collection.

Descriptive analyses were conducted to assess associations between social support and neighborhood perceptions to HIV health outcomes, and bivariate correlations were conducted to assess relationships between social support and neighborhood perceptions constructs. Univariate analyses were conducted to analyze independent relationships with sociodemographic, HIV health outcomes (viral loads, CD4 counts, and prescriptions for cART), and neighborhood perceptions.

Results

The majority of the sample was male 68.8% (n =202), with a mean age was 43.1 years (range: 18-70 years). The sample was primarily African Americans (n = 146; 72.3%), and more than half of the sample had an income under US$10 000. Nearly half of the sample (n = 98; 48.5%) had attained a high school diploma or GED or less. A large proportion of the sample was unemployed (n = 97; 48%). More than three-quarters of the sample (n = 155; 77.5%) had a current prescription for cART. Moreover, 69% of the sample (n =140) was virally suppressed (<400 copies/mL). Yet, approximately one-fifth (n= 44; 21.8%) of the sample had CD4 counts of <200 cells/mm³. Additional details are included in Table 1.

Table 1.

Sample Characteristics.^a

Characteristic	n	%
Gender
Male	139	68.8
Female	61	30.2
Age
Mean	43.1 (SD: 11.1)
Range	18-70
Race
African American/other minorities	146	72.3
Caucasian	55	27.2
Income (n = 200)
<US$10 000	102	50.5
US$10 000-US$29 999	66	32.7
US$30 000-US$49 999	29	14.4
≥US$50 000	2	1.0
Education
≤High school degree/GED	98	48.5
>High school degree	103	51.0
Employment
Unemployed	97	48.0
Employed (part- or full-time)	105	52.0
Current cART prescription	155	77.5
CD4 count (n = 197)
<200 cells/mm³	44	21.8
200-499 cells/mm³	67	33.2
>500 cells/mm³	86	42.6
HIV viral load (n = 200)
<400 copies/mL	140	69.3
≥400 copies/mL	60	29.7

Abbreviations: cART, combination antiretroviral therapy; GED, general educational diploma; SD, standard deviation.

^aN = 202.

The mean scores for each of the social support subscales were 3.7 (standard deviation [SD] = 1.0; range 1-5) for emotional support, 3.8 (SD = 1.0; range 1-5) for tangible support, 3.9 (SD = 1.1; range 1-5) for affectionate support, 3.7 (SD = 1.1; range 1-5) for positive interaction, and 4.6 (SD = 1.9; range 1-5) for the overall social support index mean score. The overall social support scale score, which can range from 0 to 100, contained the count of people who serve as social support providers in conjunction with the subscale measurement scores to provide a standardized overall social support mean score of 16.3 (SD = 8.5, with a range of 0.58-57.4). For the neighborhood perception assessments, participants reported a mean score of 2.7 (SD = 0.47; range 0-4) on the Perceived Neighborhood Disorder Scale. The Collective Efficacy Scale resulted in a mean score of 2.2 (SD = 0.62; range 1-4). The mean score of the perceived fear was 0.67 (SD = 1.5; range 0-7).

We conducted correlations to assess the relationship between social support and neighborhood perceptions. Perceived neighborhood disorder was negatively correlated with emotional support, positive interaction, and overall social support (P < .05 for all). Collective efficacy was negatively correlated with emotional support, tangible support, affection, positive interaction, and overall social support (P < .001 for all). Emotional support was negatively correlated with perceived neighborhood disorder (P < .05) and collective efficacy (P < .001). Tangible support was negatively correlated with collective efficacy (P < .001). Affection was negatively correlated with collective efficacy (P < .001). Positive interaction was negatively correlated with perceived neighborhood disorder (P < .05). Finally, overall social support was negatively correlated with perceived neighborhood disorder (P < .05) and collective efficacy (P < .001). Table 2 depicts these results.

Table 2.

Correlations between Social Support Subscales and Neighborhood Perceptions.^a

Subscales	(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)
(1) Neighborhood disorder	1.00
(2) Collective efficacy	−.416^b	1.00
(3) Perceived fear	.044	−.367^c	1.00
(4) Emotional support	−.217^c	−.254^b	−.050	1.00
(5) Tangible support	−.178	−.213^b	.153	.631^b	1.00
(6) Affectionate support	−.035	−.276^b	.132	.714^b	.653^b	1.00
(7) Positive interaction	−.247^c	−.257^b	.169	.816^b	.616^b	.763^b	1.00
(8) Overall support	−.243^c	−.227^b	−.199	.600^b	.571^b	.576^b	.588^b	1.00

^aPearson’s R presented.

^b P < .001.

^c P < .05.

We assessed the relationship between measures of neighborhood perceptions and social support, including sociodemographic characteristics (race, age, gender, annual income, and education level) and HIV management factors (including current HIV viral loads, CD4 counts, current receipt of cART prescription, and the mean number of missed appointments in the calendar year). There were no significant associations between sociodemographic characteristics and HIV management characteristics with the social support and the collective efficacy scale. Greater levels of perceived fear were independently associated with lower CD4 counts and having current cART prescriptions (Tables 3 and 4).

Table 3.

Overall Social Support Association with Neighborhood Perceptions.

Neighborhood-level scales	β	σ	P Value
Collective efficacy	−1.040	.750	.174
Perceived fear	−.036	.020	.069
Neighborhood perceptions	Missing data (n = 99)

Table 4.

Associations between Sociodemographic Characteristics, HIV-Related Parameters, and Neighborhood Perceptions.

Baseline	Collective Efficacy			Perceived Fear
Baseline	β	σ	P Value	β	σΣ	P Value
Gender
Male	.310	.450	.492	−11.744	23.342	.618
Female	.241	.454	.597	−5.412	23.477	.819
Age	−.007	.005	.157	.134	.362	.713
Race
African American/other minorities	.031	.118	.793	16.849	9.691	.090
Caucasian	-	-	-	-	-	-
Annual income
<US$10 000	−.315	.463	.497	−23.115	18.540	.220
US$10 000-US$29 999	−.469	.468	.318	−19.610	19.999	.333
US$30 000-US$49 999	−.749	.479	.120	18.272	30.020	.546
≥US$50 000	−.883	.651	.177	-	-	-
Education
≤High school degree/GED	−.004	.109	.974	−6.966	7.080	.331
>High school degree	-	-	-	-	-	-
Employment
Unemployed	−.146	.102	.156	−2.295	7.069	.747
Employed (part- or full-time)	-	-	-	-	-	-
CD4 count
<200 cells/mm³	−.103	.147	.484	−33.549	12.619	.011
200-499 cells/mm³	−.091	.116	.433	−11.501	8.594	.189
>500 cells/mm³	-	-	-	-	-	-
HIV viral load
<400 copies/mL	.069	.175	.693	−9.962	9.664	.309
≥400 copies/mL	-	-	-	-	-	-
Current cART prescription
Yes	-	-	-	-	-	-
No	.065	.145	.655	−29.400	10.586	.008*

Abbreviations: cART, combination antiretroviral therapy; GED, general educational diploma.

P value < .05.

Discussion

In this study of predominantly urban, poor African Americans living with HIV infection, limited social support was highly correlated with negative neighborhood perceptions. Specifically, perceived fear of one’s environment was a key parameter that was negatively associated with HIV-specific metrics, including lower CD4 counts and a lower likelihood of receipt of cART prescription. These findings indicate that the environmental context of social support likely affects HIV management efforts.

The social cohesion of a neighborhood, as perceived by its inhabitants, has potential to provide multiple types of social support: informational, instrumental, and emotional. Having a reliable neighbor may help individuals with HIV to overcome barriers such as transportation to their appointments, watch their children when in need, assistance with medication adherence, or a confidant to discuss issues, particularly when they are feeling distressed.⁷ Our results affirm research illustrating that social cohesion is a leading factor in defining quality of life and social support.²⁴ The fact that social support and neighborhood perceptions are highly correlated constructs indicates a comprehensive examination of the role of social support in the setting of HIV infection should include an assessment of neighborhood perceptions and social dynamics.

Nevertheless, many of the participants reported feeling unsafe in their neighborhoods and this perception directly impacted HIV-related outcomes. This finding suggests that neighborhood perceptions may be associated with nonadherence to HIV care.²⁶ Although not established in our findings, there is literature to support the hypothesis that a lack of security and safety has a powerful influence on stress and perhaps other inflammatory biomarkers.³² Our findings identified that social support and neighborhood perceptions were positively correlated, thus improving neighborhood context may be a mechanism to enhance social connectedness and improve consistent HIV care engagement.

Future intervention efforts should consider testing the impact of a community mobilization initiative on engagement in medical care. Specifically, assessing how to address HIV infection in a neighborhood-wide effort would be unique and somewhat challenging in the face of reported stigma.³³ Improving community support may prove to be an effective intervention to overcome this challenge and increase engagement in HIV care.^34,35 This type of intervention is meant to facilitate a community response to the unique issues for residents of a given neighborhood. Increasing social cohesion and support is likely to build a sustainable level of engagement for people to feel more socially connected. In essence, building a socially connected community can play a vital role in helping to bring about the change in the overall health of a neighborhood.

One limitation to our study relates to the cohort of participants being engaged in HIV clinical care. These persons have overcome 1 barrier, that is, engagement in care, and may not reflect the significant proportion of HIV-infected individuals who are aware of their status but fail to engage in care. This latter population may have different challenges and barriers to the cohort evaluated in this study. Furthermore, we did not address other gaps in knowledge specific to the context in which individuals live and how that context influences the barriers to continued care, treatment, management, and overall quality of life. Additionally, we did not have longitudinal data to determine how these factors contribute to long-term success with HIV care engagement.

Other studies reported significant relationships between social support and HIV outcomes, yet our sample did not find these results. This may be due to a relatively small sample, recruitment from a single clinic, and the fact that the sample included only persons who were engaged in medical care. Additionally, we did not analyze physical neighborhood conditions to confirm self-reported data.

Examining the integral relationship between neighborhood perceptions and social support within the context of chronic medical conditions demonstrates how environment influences health behaviors. Future studies can demonstrate whether health and medical adherence can be improved through interventions on social support and neighborhood conditions.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by the Washington University Institute of Clinical and Translational Sciences grant UL1 TR000448 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH); specifically, KL2 TR000450. The content is solely the responsibility of the authors and does not necessarily represent the official view of the NIH.

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The Relationship of Social Support and Neighborhood Perceptions among Individuals with HIV

Abstract

Keywords

Introduction

Methods

Measures

Results

Discussion

Footnotes

Declaration of Conflicting Interests

Funding

References